Release of Information Authorization Form
Phone: 913-491-8319
I, (Patient/Guardian Name)
Date of Birth
hereby authorize Richard B. Price, MD to release protected health information to:
Name of Facility/Individual
Phone
Fax
Address
City
State
Zip
Records Desired
Office Notes
Diagnostic Tests
Medication List
Labs
Other -
Patient Name
Date of Birth
Address
City
State
Zip
Patient/Guardian Signature
– Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date